Mycotic Inferior Mesenteric Aneurysm Penetrating to Duodenum: Observation of the Formative Course / 日本心臓血管外科学会雑誌

A 64-year-old woman who had a fever and low back pain was referred to our institution. Abdominal computed tomography revealed a low density area around the aorta and inferior mesenteric artery and liver abscess. Under the diagnosis of mycotic abdominal aneurysm, intravenous administration of antibiotics was started and her symptoms improved. On the 12th day after admission, the patient developed hematemesis and an emergency CT scan revealed enlargement of the low density area around the aorta and dilatation of the inferior mesenteric artery diameter to 16mm. Urgent operation was performed under the diagnosis of impending rupture of the mycotic aneurysm. Necrotic tissue and hematoma was recognized outside the aorta, and this mass firmly adhered to the duodenum. Communication between the abdominal aorta and the duodenum through the inferior mesenteric artery was confirmed. The infected aneurysmal area of the aorta was almost completely resected by closing the infra-renal aorta and terminal aorta above the bifurcation and a left axillo-femoral bypass was established. The culture of the necrotic tissue revealed <i>Klebsiella pneumoniae</i>. Antimicrobial therapy was continued and the patient was discharged from the hospital on postoperative day 46. Because the mortality rate of mycotic aneurysm penetrating to the duodenum is high, early diagnosis and treatment is important. We present a successfully treated case of mycotic aneurysm in which the formative course was observed from an early stage of infection. We observed the process of mycotic aneurysm formation and aorto-duodenal fistula generation despite antibiotic therapy. Close observation of periaortic inflammation and early surgical intervention is necessary in such patients.

Two Cases of Stent-Grafting for Ruptured Aneurysms / 日本心臓血管外科学会雑誌

In cases of stent-grafting for ruptured aneurysm, endoleak is a serious problem. We report 2 cases of ruptured aneurysms that were treated with endovascular stent-graft placement. Case 1: A 79-year-old woman had a ruptured thoracic aortic aneurysm that was treated with endovascular stent-grafting from the distal arch to the descending aorta. Although her infra-operative course was uneventful, she died suddenly the day after operation. Autopsy revealed re-rupture of the aneurysm due to endoleak from the proximal site. Case 2: An 84-year-old woman was treated with endovascular stent-grafting for ruptured abdominal aortic aneurysm. The stent-graft was inserted from the infra-renal abdominal aorta to the right common iliac artery with femoro-femoral crossover bypass placement. There was evidence of type II endoleak that occurred via the left internal iliac artery (IIA) and inferior mesenteric artery (IMA) 16 days after surgery. A CT scan performed 6 months after surgery revealed an increase in aneurysm size and persistent type II endoleak. Both embolization of the aneurysmal sac through the IMA and surgical ligation of the IMA failed, and endoleak from the IMA persisted. Re-rupture of the aneurysm occurred 10 months after initial surgery and emergency open surgery was performed. In stent-grafting for ruptured aneurysms, only the thrombus outside the graft resists the pressure caused by the endoleak. We conclude that endoleak after stent-grafting for ruptured aneurysm should be treated completely as soon as possible because of the risk of re-rupture.

Early and Mid-Term Results of Endovascular Stent-Graft Placement for the Treatment of Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

We performed endovascular stent-graft placement on 39 patients with abdominal aortic aneurysms between 1996 and March 2002-a period of approximately 5 years (first half: until the end of June 1998, second half: July 1998 onward). Three patients in the first half of the period and 8 patients in the second half were 80 years or older. Two cases of mycotic aneurysm were observed. During the second half, we encountered high-risk cases in which the patients had complications such as coronary artery disease (5 patients), COPD (1 patient) and thoracic aortic aneurysm (4 patients). Although we had to switch to surgery in 3 patients during the first half of the period, we successfully placed stent-grafts in the other 36 cases (92%). Endoleaks were observed in 6 patients, and dissection of the iliac artery was observed in 5 patients (stents had been placed in all patients). In 50% of all cases in the first half of the period and 89% of all cases in the second half, stent-graft placement was successful and no endoleak was observed. During the follow-up period, 3 cases required additional treatment, and another 4 cases required surgery. Four patients died in hospital during the first half of the period, and 3 patients died during the following 3 years. The 3-year survival rate was 82%. It was considered that stent-graft placement for abdominal aortic aneurysms is particularly effective for high-risk patients, and that the results of this type of therapy will improve in the future.

A Case Report of Double Aortic Arch, Vascular Ring Associated with Tracheal Stenosis / 日本心臓血管外科学会雑誌

We report a case of vascular ring with tracheal stenosis, which might be related to a prolonged endotracheal intubation. A symptomatic 2-month-old boy was admitted to our institution after prolonged intubation without a definite diagnosis. His symptoms were stridor and dyspnea, but not dysphagia. Echocardiography detected a vascular ring and this was confirmed by computed tomography and magnetic resonance imaging (MRI) (Edwards IA type). The left anterior aortic arch was divided distal to the left subclavian artery through left thoracotomy and the ligamentum arteriosus was not identified. On postoperative day (POD) 2, endotracheal extubation was unsuccessfully attempted. Further examination such as MRI and bronchoscopy revealed intimal hyperplasia of the trachea with mild compression of the trachea from the outside. We performed aortopexy and division of the small long ductus which might not be a mechanism of the tracheal compression through right thoracotomy in the second operation with successful extubation on POD 3. The patient has been discharged from the hospital and followed up at the outpatient clinic without any symptom. Tracheomalacia was a common associated anomaly in vascular ring. However, other mechanisms such as inflammatory reaction associated with prolonged intubation should be considered and be avoided in the pediatric population.